Category Archives: Veterans

A national veterans task force is advocating radical changes in the medical system for America’s former military personnel, including a choice to receive subsidized private care and conversion of the Veterans Health Administration into a non-profit corporation rather than a government agency.

On Capitol Hill, lawmakers resume work this week to resolve differences over legislationaimed at alleviating long wait times for medical care at the Department of Veterans Affairs hospitals and clinics after reports that some veterans may have died awaiting appointmentsand that some VA staff falsified records to cover up excessive wait times.

Five senior VA leaders – including former department secretary Eric Shinseki –have resigned in the past six weeks.

Both the House and Senate have passed bills that would allow veterans to seek medical care outside of the VA system if they meet certain conditions, including living more than 40 miles from a VA medical facility.

Dr. Kenneth Kizer

Dr. Kenneth Kizer, a former VA undersecretary for health, spoke recently with KHN’s Mary Agnes Carey about the issue of the VA contracting with outsideproviders for medical care.

Kizer, the founding chief executive officer and president of the National Quality Forum, is now director of the Institute for Population Health Improvement at the University of California, Davis.

Jerral Hancock wakes up every night in Lancaster, Calif., around 1 a.m. dreaming he is trapped in a burning tank. He opens his eyes, but he can’t move, he can’t get out of bed and he can’t get a drink of water.

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

Hancock, 27, joined the Army in 2004 and went to Iraq, where he drove a tank. On Memorial Day 2007 — one month after the birth of his second child — Hancock drove over an IED. Just 21, he lost his arm and the use of both legs, and now suffers from post-traumatic stress disorder.

The Department of Veterans Affairs pays him $10,000 every month for his disability, his caretakers, health care, medications and equipment for his new life.

Stacie Tscherny dropped everything to take care of her son, U.S. Army veteran Jerral Hancock, when he came home from Iraq without an arm. She helps take care of his two children now as well. (Photo by Jessica Wilde/News21)

No government agency has calculated fully the lifetime cost of health care for the large number of post-9/11 veterans of the wars in Iraq and Afghanistan with life-lasting wounds.

But it is certain to be high, with the veterans’ higher survival rates, longer tours of duty and multiple injuries, plus the anticipated cost to the VA of reducing the wait times for medical appointments and reaching veterans in rural areas.

“Medical costs peak decades later,” said Linda Bilmes, a professor in the Kennedy School of Government at Harvard University and coauthor of “The Three Trillion Dollar War: The True Cost of the Iraq Conflict.”

As veterans age, their injuries worsen over time, she said. The same long-term costs seen in previous wars are likely to be repeated to a much larger extent.

Post-9/11 veterans in 2012 cost the VA $2.8 billion of its $50.9 billion health budget for all of its annual costs, records show. And that number is expected to increase by $510 million in 2013, according to the VA budget.

Like Hancock, many veterans returning from Iraq and Afghanistan have survived multiple combat injuries because of military medicine’s highly advanced care. Doctors at Brooke Army Medical Center in San Antonio repaired Hancock’s body with skin grafts and sent him to spinal-cord doctors for the shrapnel that ultimately left him paralyzed. He still has his right arm, but he can only move the thumb on his right hand.

Injuries like Hancock’s likely will lead to other medical issues, ranging from heart disease to diabetes, for example, as post-9/11 veterans age.

“So we have the same phenomenon but to a much greater extent,” Bilmes said. “And that drives a lot of the long-term costs of the war, which we’re not looking at the moment, but which will hit in 30, 40, 50 years from now.”

Veterans like Hancock with polytraumatic injuries will require decades of costly rehabilitation, according to a 2012 Military Medicine report that analyzed the medical costs of war through 2035. More than half of Iraq and Afghanistan veterans are between the ages of 18 and 32, according to 2011 American Community Survey data. They are expected to live 50 more years, the Institute of Medicine reports.

About 25 percent of post-9/11 veterans suffer from post-traumatic stress disorder, and 7 percent have traumatic brain injury (TBI), according to Congressional Budget Office analyses of VA data. The average cost to treat them is about four to six times greater than those without these injuries, CBO reported. And polytrauma patients cost an additional 10 times more than that.

Post-9/11 veterans use the VA more than other veterans and their numbers are growing at the fastest rate. Fifty-six percent of Iraq and Afghanistan veterans use the VA now, and their numbers are expected to grow by 9.6 percent this year and another 7.2 percent next year, according to a VA report from March 2013.

Hancock drove over an IED in Iraq in 2007. Hancock’s stepfather, Dirrick Benjamin, helps him take his medication. He and Hancock’s mother take care of him full time, helping him with everyday tasks like getting dressed and drinking water. (Photo by Jessica Wilde/News21)

In response to multiple injuries suffered by Iraq and Afghanistan veterans, the VA established its polytrauma care system in 2005, creating centers around the country where veterans are treated for multiple injuries, ranging from TBI and PTSD to amputations, hearing loss, visual impairments, spinal-cord injuries, fractures and burns.

Post-9/11 veterans make up around 90 percent of polytrauma patients, said Susan Lucht, program manager of the polytrauma center at the Southern Arizona VA Health Care System in Tucson.

Each polytrauma patient costs the VA on average $136,000 a year, according to a CBO report, using VA data from 2004 through 2009. And many of their medical issues will never go away.

One TBI patient at the Tucson center, Erik Castillo, has received speech, physical, occupational, psychological and recreational therapies for all of the paralysis, cognition and memory issues associated with injuries he received in a bomb blast in Baghdad.

But Castillo’s treatment is exactly what medical professionals and economists say could potentially be cost-saving as well as life-saving.

If the VA treats primary injuries early on and creates a community and family support system, it might be able to lower costs later, said Dr. James Geiling, Dr. Joseph Rosen and Ryan Edwards, an economist, in their 2012 Military Medicine report.

“And those are the costs that we’re trying to reduce by giving the care that we do,” said Dr. G. Alex Hishaw, a staff neurologist at the Tucson center.

Castillo has been living with TBI for nine years, and he still goes to the VA three times a week for therapy. “I’ll utilize the VA for the rest of my life,” he said.

The shrapnel that entered Castillo’s brain from a bomb in Baghdad in 2004 burned a portion of his frontal lobe, which had to be removed. Doctors told his parents that he wouldn’t survive and that if he did, he would need care for the rest of his life.

Slowly, Castillo started to re-create himself. He learned to talk again, to eat again, to move his left arm and leg. Now, he is going to college.

“We want them to graduate,” Lucht said. “But they always know that this is their foundation. This space is here. And their needs will change as they age.”

As Hancock and other post-9/11 veterans age, they will need increased medical care and will become more expensive for the VA. The injuries they have now will likely lead to more complicated and expensive medical issues. TBI, for example, may lead to greater risk of Alzheimer’s disease, psychological, physical and functional problems, and alcohol-abuse disorders.

Doctors and economists argue that today’s conversation should not only be about the primary wounds of war, but about the medical issues that are often associated with them. PTSD, for example, is often associated with smoking, substance abuse, depression, anxiety, heart disease, obesity and diabetes. Amputations are associated with obesity, cardiovascular disease, osteoarthritis, back pain and phantom limb pain.

“We should help an amputee to reduce his cholesterol and maintain his weight at age 30 to 40, rather than treating his coronary artery disease or diabetes at age 50,” Geiling, Rosen and Edwards wrote.

“Society is not yet considering the medical costs of caring for today’s veterans in 2035 — a time when they will be middle-aged, with health issues like those now seen in aging Vietnam veterans, exacerbated by comorbidities of post-traumatic stress disorder, traumatic brain injury and polytrauma,” they wrote.

Polytrauma centers have expanded across the country. But that doesn’t mean that all veterans live close enough to access them. In many parts of country, health care is hampered by distance because veterans who use the VA live far away from their closest VA hospital.

For Army Spc. Terence “Bo” Jones, it is more important that he live near his family.

U.S. Army Spc. Terence “Bo” Jones stepped on an IED in Afghanistan in 2012, and lost both of his legs. Now an outpatient at the VA polytrauma center in San Antonio, Texas, Jones is learning to walk on prostheses and drive an adapted car with only his hands. (Photo by Jessica Wilde/News21)

Jones lost both of his legs to an improvised explosive device blast in Afghanistan in 2012. Like Hancock, Jones woke up at Brooke Army Medical Center with his family by his side.

He was 21 when he stepped on the IED. It shot him 10 feet into the air and he landed in a nearby well. He doesn’t remember it, but his friends told him he was conscious and trying to climb out.

Now an outpatient at the VA polytrauma center in San Antonio, Jones is learning to walk on prosthetic legs, provided to him by the VA. The VA also provides adaptive driving equipment for his car, and he is taking driver education to learn how to drive with only his hands. One day, he hopes to get a service dog, and the VA will pay for veterinary care and equipment for the dog to help its owner.

“We can get them anything that they need,” Lucht said.

The VA provides other assistive accommodations for injured veterans — from grab bars and walk-in showers to wheelchairs and specialized seating. And a lot of veterans wear out their prosthetic limbs because they’re active, Lucht said.

When Jones finishes rehab, he plans to move home to Idaho, go to college and open his own shop doing custom cars and motorcycles. But in Idaho, Jones won’t be near a polytrauma center anymore.

One of the most rural veteran populations in the country is served by the Reno, Nev., VA hospital, said Darin Farr, the hospital’s public affairs officer. “We’re actually considered frontier,” he said.

The hospital’s patients come from as far away as 280 miles. More than 29,000 veterans are enrolled in the Reno hospital, staffed by 1,200 employees, only 40 to 50 percent of whom actually provide medical care.

Many VA hospitals fall behind in entering data from private health records or following up with patients, especially mental health patients for whom follow-up care is particularly important, according to VA Office of Inspector General reports.

The VA doesn’t always provide timely mental health evaluations for first-time patients, and existing patients often wait more than the recommended 14 days for their appointments, the OIG reported last year.

Veterans have complained for many years about long wait times to schedule appointments. “Long wait times and inadequate scheduling processes at VA medical centers have been long-standing problems that persist today,” the U.S. Government Accountability Office reported in February. Inconsistent scheduling policies, staffing, phone access and an outdated scheduling system make the problem worse.

Meanwhile, both the GAO and OIG have reported that VA’s data on wait times for medical appointments is unreliable, and some schedulers entered incorrect dates or changed them to meet performance standards.

Farr says the Reno hospital faces unique challenges that might contribute to wait times. The hospital competes with other hospitals for employees who might pay more than the government does.

“We don’t have a lot of space,” he added. The hospital schedules more than 373,000 outpatient visits and 4,200 inpatient visits every year. But it only has 64 hospital beds — 14 psychiatric, 12 ICU and only 38 for general use.

When Terence Jones finishes rehab at the polytrauma center in San Antonio, he hopes adaptive equipment will help him return to a normal life. Jerral Hancock, on the other hand, knows that he never will.

Hancock misses the adrenaline rush of life before his injury. He longs for a wheelchair that will go faster than 5 mph. He described the time he fell out of his hospital bed as exhilarating. He busted his cheek open, but he loved it.

With the $100,000 the Defense Department gave Hancock for his injuries when he was discharged, he bought two mobile homes outside Los Angeles, one for him and his two children, ages 9 and 6, and one for his mother and stepfather, who take care of him full time. Hancock supports all of them with his monthly disability check from the VA.

The VA bought him a wheelchair and put a lift into his front porch. They widened the doors in his mobile home so his wheelchair could fit in and out. They will pay for his medications and all of his medical care for the rest of his life.

When Hancock arrived at his new mobile home, he couldn’t fit his wheelchair in the front door. So he kept one wheelchair inside, and his stepdad carried him through the door and down the steps to a second wheelchair that he paid for himself. It took eight months for the VA to pay him $1,000 for the second wheelchair, and four months to put a lift into his front porch.

“I was stuck in the house for six months over this fight,” Hancock said. “I had a wheelchair upstairs and I had a wheelchair downstairs. And my caretaker carried me up and down the stairs from wheelchair to wheelchair. It was ridiculous.”

The VA also bought Hancock an $85,000 arm that he could attach to his shoulder to use. But he can’t seem to get it to work.

The VA gave Hancock $11,000 toward a car, but his mother said that doesn’t come close to the cost of a handicap-equipped vehicle. Instead, he bought a seven-passenger bus with a lift for his wheelchair.

Even with all of the money that the VA spends on Hancock’s medical and family care, he still lives in a mobile home, and his bedroom has little extra space with a hospital bed and a wheelchair in it. He can’t fit into his kids’ bedrooms. He can’t drink a glass of water on his own. And his air conditioning hardly works, even though he can’t be in the heat for too long because his burns prevent him from sweating.

Hancock’s children also have had to adjust.

“My son watched me walk off — he was going on 3 — and I jumped on a bus with a couple hundred pounds of gear,” he said. “The next time he saw me, I lost 100 pounds … I looked like a skeleton and I had tubes coming out everywhere … My daughter, this is all she knows.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Veterans, who already face a lengthy backlog in getting help, risk not getting their disability and pension benefits at all next month if the federal government shutdown lasts several weeks.

The Department of Veterans Affairs said it has enough money to process veterans’ claims for pensions, compensation, education and vocational rehabilitation programs through late October, but a prolonged shutdown would suspend those programs once the money runs out.

And while veterans’ medical care is protected, some call centers and hotlines have already been suspended under the budget impasse between Congress and the White House.

“B/c of #shutdown, @VAVetBenefits overtime ends today. After decreasing backlog 30%, we project it will start increasing,” Tommy Sowers, assistant secretary for public and intergovernmental affairs at the VA, tweeted on the first day of the shutdown.

States play a key role in ensuring that veterans receive their benefits. Ever since World War II, each state has developed its own department or agency specifically to manage veterans’ affairs.

Once the state processes a veteran’s pension, compensation and disability claim, that claim is then sent to the federal VA “and at that time, it’s out of our control,” said Robert Horton, spokesman for the Alabama Department of Veterans Affairs, with the federal VA either approving or rejecting the claim.

The federal VA has been widely criticized for the backlog. As of Sept. 28, the VA said there were 725,469 casespending, 58 percent of them for more than 125 days.

“If the federal VA has to lay off employees, then claims won’t be processed and veterans possibly won’t receive their benefits or payments for pension and compensations, but right now there is no effect on the state VA,” Horton of the Alabama VA said.

Which VA Services Are Protected?

All VA medical facilities and clinics will remain fully operational during the federal shutdown, including VA hospitals. In 2009, Congress passed a law to fund the VA one year in advance.

This allows the VA health care system to plan ahead and ensures that VA health care is funded for an additional year beyond the government shutdown, according to a “Government Shutdown FAQ” from Tom Tarantino, chief policy officer for the Iraq and Afghanistan Veterans of America (IAVA), a nonprofit, nonpartisan organization for new veterans.

Also not affected are VA medical appointments, prescription drug phone lines, home loan processing and veterans’ crisis lines, according to the VA’s “Field Guide to Government Shutdown.”

“While veterans may be more protected than other constituencies, a government shutdown does not bode well for top priorities within the veterans’ community,” Tarantino wrote.

Among the VA services that are affected under the shutdown:

Call centers and hotlines related to education and consumer affairs are suspended as well as the Inspector General Hotline (1-800-488-8244).

No decisions on claims appeals or motions will be issued by the Board of Veterans Appeals.

The VA’s Veterans Benefits Administration will not be able to continue overtime for claims processors.

Recruiting and hiring of veterans job applicants will cease with the exception of the Veterans Health Administration.

Bill Allman, project analyst at the Washington state’s veterans benefit enhancement projects, called the shutdown unfortunate. His department has spearheaded a project that has moved nearly 10,000 veterans from the state’s Medicaid rolls to the VA’s health care system using a federal database known as the “Public Assistance Reporting Information System,” or PARIS.

Allman said the federal manager of the PARIS system has been furloughed until a budget resolution can be reached. “This may drag on much longer than any of us predicted,” he said. “It really drives home the impact that the shutdown has on people’s lives, as well as the additional work that it creates for others.”

Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

More than a quarter-million veterans who lack health insurance will miss out on Medicaid coverage because they live in states that have declined to expand the program under the Affordable Care Act.

Expanding Medicaid eligibility is a key component of the new federal health law, which aims to provide coverage to the vast majority of uninsured Americans.

In January, uninsured adults with incomes at or below 138 percent of the federal poverty level ($15,415 for an individual and $32,527 for a family of four) will become eligible for Medicaid benefits in states that expand their programs.

Many people assume that the nation’s 12.5 million non-elderly veterans receive health benefits through the Department of Veterans Affairs (VA). But only two-thirds of those veterans are eligible for VA health care and only one-third are enrolled.

Nationwide, there are about 1.3 million uninsured veterans.

In a recent report, the Urban Institute estimated that if every state embraced the new Medicaid rules, as many as 535,000 uninsured veterans and 174,000 veterans’ spouses would become eligible for Medicaid coverage.

But last June the U.S. Supreme Court, while upholding the Affordable Care Act as a whole, ruled that states were not required to expand their Medicaid programs. Twenty-three states have declined to do so, and another six have not made a final decision.

In the 23 states rejected the expansion, there are approximately 258,600 uninsured veterans who would have been eligible for Medicaid, according to the Urban Institute report.

Like most other Americans, the veterans who don’t have health insurance will have to get it by January or risk paying a penalty under the Affordable Care Act.

However, some of the uninsured veterans who don’t qualify for Medicaid coverage might be eligible for federal subsidies that will be available under the law. Uninsured Americans—veterans and non-veterans—will be able to use those subsidies to purchase private insurance on the state health care exchanges that will launch in January.

Some worry that the expanding—and potentially confusing—array of health insurance choices available to veterans will lead to worse care.

The federal government created a separate VA health care system in the belief that veterans would get better care from doctors and nurses knowledgeable about the unique health conditions facing them, which include post-traumatic stress as well as other mental illnesses and physical injuries.

But the Department of Veterans Affairs expects only 66,000 uninsured veterans to enroll in the VA system to meet the insurance requirement under the new health law.

The income limits for VA benefits are much less stringent than they are for Medicaid. A veteran with no dependents and an annual income of as much as $30,978 (the amount varies based on the cost of living in a particular area) is eligible.

But conditions other than income—such as length of time since combat, service medals, and service-related injuries or illnesses—also affect eligibility for VA health benefits.

In addition, “there may be a variety of factors why a veteran would choose (Medicaid) or the (VA), such as proximity to VA facilities or their knowledge of the fact that VA care is available to them,” according to Jennifer Haley, who co-authored the Urban Institute report.

Kenneth W. Kizer, a former Clinton administration official widely credited for enacting substantial improvements to the VA health care system during the 1990s, has warned that there are risks to providing care to veterans in a variety of venues.

In an article published last year, he argued that doing so “diminishes continuity and coordination of care, resulting in more emergency department use, hospitalizations, diagnostic interventions and adverse events.”

Kizer, who is now director of the Institute for Population Health Improvement at the University of California Davis, pointed to data suggesting that patients who receive care in both VA and non-VA facilities are more likely to be re-hospitalized and to die within a year, compared to those who receive VA-only care.

Some veterans’ organizations, including the American Legion, urge all eligible veterans to turn to the VA health care system first.

“The American Legion believes that all veterans should be treated by the VA,” said Jacob Gadd, deputy director for health care at the American Legion.

Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

Military veterans will have more health insurance options under the Affordable Care Act, but some vets, like many Americans, may still struggle to find affordable, accessible care that meets their needs.

Roughly 40 percent of the 22.3 million military veterans receive health-care services from the Veterans Health Administration, which operates a nationwide network of medical centers, hospitals and clinics.

Many veterans are eligible for both VA health care and Medicare, Medicaid or Tricare, the health plan for active and retired military and their families. About half of veterans have private insurance; approximately one in 10 veterans younger than 65 are uninsured.

Veterans who were honorably discharged after being on active duty for at least two years may qualify for VA health services. Since funding for the VA health program is limited, however, priority is given to veterans who have service-related disabilities or low incomes.

Under the Affordable Care Act, most people will have to have health insurance starting in January or pay a penalty. Veterans who are enrolled in VA health care won’t have to buy additional coverage, although they can supplement their coverage if they want to.

Mike Sage, 64, a Vietnam War combat veteran, pays $15 per visit for primary-care services and $50 for specialist care at the VA clinic near his home in Monmouth, Ill.

Prescription drugs are $8 for a 30-day supply. But his wife, Kay, like many veterans’ spouses, doesn’t qualify for VA health care. They plan to check out the policies offered on the Illinois health insurance exchange this fall to see if there’s a better option than the catastrophic-coverage plan with a $5,000 deductible that she currently carries.

Sage was relieved to learn that his VA health care counts as coverage under the ACA. “As long as I’m not subject to a penalty [for not having insurance], we’ll do some comparative shopping for her,” he says.

The expansion of Medicaid under the Affordable Care Act — which states are currently wrestling over whether to implement — could also affect veterans’ health care. The law allows the expansion of the federal-state program for low-income people to include adults with incomes up to 138 percent of the federal poverty level ($15,856 in 2013).

According to an analysis published by the Urban Institute last month, four in 10 uninsured veterans have incomes below 138 percent of the federal poverty level, potentially enabling them to qualify for Medicaid if their states expand the program. Most of those veterans have incomes below 100 percent of the poverty level.

“For these veterans, it’s critical that their state expand Medicaid,” says Jennifer Haley, a research associate at the Urban Institute who co-authored the report.

In states that don’t expand their programs, veterans whose income falls below 100 percent of the poverty level will generally not qualify for Medicaid, nor for subsidized coverage on the exchanges.

Even though a non-disabled veteran may meet the income threshold for VA health care — nationally, about $34,000, further adjusted by geographic location — he or she may not live near VA facilities or know that VA care is available, according to the report.

At a hearing last month before the House Committee on Veterans’ Affairs, VA officials said they expect a net increase of 66,000 veterans seeking health care through VA facilities when the mandate to have health insurance kicks in next year.

Some veterans will come into the VA system but others will leave to seek coverage on the exchanges or through Medicaid, they said. Those who are eligible for more than one health program may pick and choose, using one program for cheaper prescription drugs, for example, and another for specialist care.

But more choices may not mean better care, says Kenneth Kizer, director of the Institute for Population Health Improvement at the UC Davis Health System.

In an opinion piece published last year in the Journal of the American Medical Association, Kizer, a former VA official, noted that having access to multiple plans can lead to fragmented care, increasing the chances of errors and other complications.

“Tests get repeated, drugs get prescribed that may not be compatible with each other,” he says. “One provider may not realize what the other is doing.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

As more and more soldiers return from recent conflicts overseas, new research reveals that female veterans experience poorer health than other women.

In 2010, women made up 8 percent of the U.S. veteran population, according to the U.S. Department of Veterans Affairs (VA).The study, appearing in the American Journal of Preventive Medicine, is the first to demonstrate how female veterans’ health status differs from their civilian and active duty counterparts, even when controlling for access to health care.

KEY POINTS

Female veterans are more likely to smoke, be overweight or obese and have heart disease compared to civilian women and women in the National Guard or Reserves, even when controlling for access to health care, according to a new study.

“While we found that women veterans were more highly educated, had higher incomes and were more likely to have health insurance, they reported worse health compared to active duty, National Guard or Reserves and civilian women across a host of outcomes,” said lead author Keren Lehavot, Ph.D., of the VA Puget Sound Health Care System in Seattle.

The study used data from the 2010 Behavior Risk Factor Surveillance Survey, a national phone survey that included 274,399 civilian women, 4,221 veterans, 661 active duty military and 995 women in the National Guard or Reserves. Researchers asked each person about her access to health care and health status.

Women veterans were more apt to smoke, be overweight or obese and have heart disease compared to civilian and National Guard or Reserve women. Veterans also reported more instances of depression and anxiety.

Yet, it was not all bad news for women in the military. Women who were serving on active duty had better access to health care, better physical health and were less prone to engage in risky health behaviors.

The researchers did not determine potential reasons for these disparities, but Lehavot said previous studies suggest that women veterans’ increased exposure to violence as well as inadequate social support might be associated with poorer health.

“We need additional research to determine if these, and other factors, help explain the differences we found,” she said.

Lehavot added that there have been changes in the Veterans Health Administration in recent years to reach out to women veterans and facilitate their access to care.

So why aren’t women currently using the health services available to them within VA medical system?

Chloe Bird, Ph.D., a senior sociologist at the RAND Corporation and expert on women’s health issues, said many factors, including geography, could determine whether women utilize the VA.

“For example, not all veterans live within easy access to a VA medical center, and the VA is far better recognized for their men’s health care than for women’s health care,” she explained. “Many women veterans may associate the VA with images of a place that serves a population of older men.”

Bird agreed that specialized outreach and other targeted interventions could improve the health and well being of the women veteran population.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Scientific review kicks off to weigh treatment for brain-injured soldiers

The Institutes of Medicine kicked off its yearlong study of cognitive rehabilitation therapy on Monday, a process that will help the Pentagon decide whether its health plan will cover the treatment for troops who have suffered brain injuries in Iraq and Afghanistan.

We’ve previously reported that Tricare, which covers troops and many veterans, relied on a controversial study to deny coverage for the treatment, which helps rewire soldiers’ brains to perform basic tasks such as memorizing lists and following orders. Tricare said the study showed there wasn’t enough evidence to support paying for the treatment, which can cost more than $50,000 per soldier. The Pentagon says nearly 200,000 troops have suffered traumatic brain injuries since the wars began, though our own reporting shows the numbers are probably a lot higher.

Did you or a loved one suffer a mild traumatic brain injury (concussion) while serving? ProPublica and NPR want to hear your story. Tell us about your experiences with TBI.

The IOM panel of experts will review scientific literature and ultimately render a decision on whether it supports the efficacy of cognitive rehabilitation therapy. If the experts reach this conclusion, they will hardly be the first to do so. In April 2009, a consensus panel assembled by the Pentagon said the therapy works, especially for soldiers suffering more severe forms of brain injury. Other groups, such as the Brain Injury Association of America, have weighed in to support it. Even some major private insurance companies pay for it.

The head of the IOM panel, Georgetown University neurologist Ira Shoulson, pointedly quizzed Tricare on this issue at Monday’s session, asking what the current review would produce that previous reviews had not.

Capt. Robert DeMartino, Tricare’s director of behavioral health, said he hoped the panel would be able to pinpoint what types of cognitive rehabilitation works best, and what kind of civilian doctors and clinicians were best qualified to provide it. He noted that stories published last year by ProPublica and NPR have cast a “shadow” over the issue, prompting congressional committees and lawmakers to pressure Tricare to provide cognitive rehabilitation therapy.

“For us, we know that we’re in a field like a gray zone,” said DeMartino, who addressed the panel by speakerphone. “We want to make sure the [treatments] that work are the ones we are going to use.”

The IOM review will continue through the end of the year, and the panel expects to convene other public sessions to help them arrive at a determination.

As Congresswoman Gabrielle Giffords begins rehabilitative therapy in Houston after being shot in the head in Tucson earlier this month, she was transferred today to TIRR Memorial Hermann, a premier rehabilitation hospital renowned for its treatment of traumatic brain injuries.

On its website, the hospital calls itself “one of very few hospitals in the country designated as a model system for traumatic brain injury.” Among the techniques it relies on is cognitive rehabilitation therapy, a tailored type of medical treatment designed to retrain the brain to do basic tasks.

It’s a treatment that Rep. Giffords will likely end up receiving, if doctors’ general descriptions of her care plan are any indication. Dr. John Holcomb, a retired Army colonel and trauma surgeon at Memorial Hermann, has described Giffords’ treatment as a “tailored and comprehensive

If Giffords does end up receiving it, she’ll be getting a treatment that many troops don’t. As we’ve reported, the Pentagon’s health program, Tricare, has refused to cover cognitive rehabilitation therapy for the tens of thousands of service members who have suffered brain injuries in the line of duty. Tricare, which provides insurance-style coverage to troops and many veterans, does cover speech and occupational therapy, which are often part of cognitive rehabilitation.

We’ve called the hospital to get further details about Giffords’ treatment plan but have not yet received that information. News reports have described her treatment as using “high-tech tools to push the brain to rewire itself,” with a focus on her physical abilities, speech, vision, cognitive skills and behavior.

The latter, as we’ve reported, has been called one of the signature wounds of the Iraq and Afghanistan wars, and tens of thousands of cases have been left undiagnosed by the military’s medical system.

Though top brain specialists have endorsed cognitive rehabilitation as an effective treatment for brain injury, Tricare officials have said that scientific evidence does not justify providing it comprehensively to troops.

To support that position, officials cite a 2009 Tricare-funded assessment of cognitive rehabilitation therapy—an assessment that internal and external reviewers have called “deeply flawed,” “unacceptable” and “dismaying,” as we reported last month with our partners at NPR.

Last week, Sen. Claire McCaskill, chairman of the subcommittee on contracting oversight, cited our findings while announcing an investigation into the Pentagon’s decision to deny treatment of traumatic brain injuries to troops. In 2008, McCaskill was one of 10 senators—including then-Senator Barack Obama—who signed a letter to Defense Secretary Robert Gates urging the military to provide Tricare coverage of cognitive rehabilitation “so that all returning service personnel can benefit from the best brain injury care this country has to offer.”

WASHINGTON, D.C.–A key congressional oversight committee announced today that it was opening an investigation into the basis of a decision by the Pentagon’s health plan to deny a type of medical treatment to troops with brain injuries.

Sen. Claire McCaskill, D-Mo., the chairman of the subcommittee on contracting oversight, said she wanted to examine a contract issued by Tricare, an insurance-style program used by soldiers and many veterans, to a private company to study cognitive rehabilitation therapy for traumatic brain injury. Such injuries are considered among the signature wounds of the wars in Afghanistan and Iraq.

The study, by Pennsylvania-based ECRI Institute, found insufficient or weak evidence to support the therapy. Often lengthy and expensive, cognitive rehabilitation programs are designed to rewire soldiers’ brains to conduct basic life tasks, such as reading books, remembering information and following instructions. ECRI’s findings ran counter to several other studies, including ones sponsored by the Pentagon and the National Institutes of Health, which concluded that cognitive rehabilitation was beneficial.

In a letter to Defense Secretary Robert Gates, McCaskill cited an investigation by ProPublica and NPR in December, which found that top scientific experts had questioned the Tricare-funded study in confidential reviews, calling it “deeply flawed” and “unacceptable.”

“If true, these reports raise significant questions regarding the Department’s award and management of the contract with ECRI Institute, and may have profound implications for hundreds of thousands of injured service members and their families,” McCaskill wrote. “We owe it to our brave service members to find the truth.”

The ProPublica and NPR investigation also found that senior Pentagon officials have worried about the high price of the care, which can cost more than $50,000 per patient. Some studies estimate that as many as 400,000 troops have suffered traumatic brain injuries in the war zones, though only a small percentage of them would need a full-scale program of cognitive rehabilitation therapy.

McCaskill joins a growing chorus demanding that Tricare reconsider its decision to deny coverage for cognitive rehabilitation. In recent weeks, the American Legion, the nation’s largest veterans’ organization, called on Tricare to provide treatment. Sen. Bob Casey, D-Penn., chairman of the Senate Foreign Relations subcommittee with oversight of the Middle East, sent a letter to Gates asking for an explanation of Tricare’s stance.

McCaskill was also one of the senators who signed a letter in 2008 asking Gates to direct Tricare to begin providing cognitive rehabilitation to troops. This November, the Pentagon sent a response to Congress informing them of the Tricare study’s findings. George Peach Taylor Jr., then-acting assistant secretary of defense for health affairs, said the Pentagon would continue to study the treatment, with another report expected later this year.

In strongly worded response on Jan. 19, McCaskill said that the senators who signed the original letter believed that enough evidence existed on the treatment’s benefits to justify covering the cost for brain-damaged soldiers.

She asked for Gates to provide her committee with a series of documents on the contract and critical scientific reviews by Feb. 18.

“While we agreed that further research on cognitive rehabilitation therapy was appropriate, we also called on the Defense Department to err on the side of providing this proven treatment to service members,” McCaskill wrote.

ProPublica and NPR have filed a similar request under the Freedom of Information Act, but Tricare has denied access to the documents, giving contradictory explanations for why. ProPublica and NPR have appealed.

Tricare officials have said their decision to deny cognitive rehabilitation is based on regulations requiring scientific proof of the efficacy and quality of treatment. They have said that the study by ECRI highlighted a lack of rigorous evidence proving the therapy’s benefits.

Traumatic brain injuries have been called the “signature wound” of the wars in Iraq and Afghanistan. While improvements in armor and battlefield medicine mean more soldiers are surviving bomb blasts that would have killed them in previous wars, the explosions are leaving some of them with permanent wounds. Mild traumatic brain injuries are difficult to detect as they leave behind no obvious signs of trauma. While many soldiers recover fully from the injury, others are left with persistent mental and physical problems.

Tricare officials also noted that the agency does cover some types of treatment considered part of cognitive rehabilitative therapy. For instance, Tricare will pay for speech and occupational therapy, which plays a role in cognitive rehabilitation. Tricare officials deny that cost played any role in their decision. In a statement, Tricare said the care of troops was their “utmost” concern.

Tricare did not immediately return requests for comment on McCaskill’s investigation.

ECRI defended its study. The non-profit institute, which has carried out numerous health reviews for Tricare, other agencies and hospital and medical groups, said they applied standard protocols in reviewing scientific literature about the efficacy of cognitive rehabilitation therapy. ECRI provided a document explaining its review here.

“The issue of how well cognitive rehabilitation therapy works for traumatic brain injury is important,” said Jeffrey C. Lerner, the president and CEO of ECRI Institute. “ECRI Institute is fully committed to providing information to the U.S. Senate on our report and methodology.”

Illustration by Zoran Ozetsky

News round up

Vets with PTSD need community services

In an op-ed piece in today’s Seattle Times, David R. Stone, CEO of social services organization Sound Mental Health, says the Veterans Affairs Administration will not be able to provide the help needed by the estimated one in five Iraq and Afghanistan war veterans who will suffer from post-traumatic stress disorder.

“The VA is an institution-based care system and was never intended to meet the needs of 300,000 victims of PTSD. These veterans and their families will be much better served by the national network of outpatient community mental-health providers already in existence . . . .

“It is incumbent upon us to demand that appropriate community-based services be made available to these brave folks who — through no fault of their own — are bringing the war home with them. We owe them that much, and we should not sleep until we pay that debt … so they can sleep better as well.”

Spinal tap test for Alzheimer’s disease

Researchers have shown that a spinal fluid test can accurately predict whether a person with memory problems is going to go on to develop Alzheimer’s disease, writes Gina Kolata in today’s New York Times.

Kolata writes:

So the new results also give rise to a difficult question: Should doctors offer, or patients accept, commercially available spinal tap tests to find a disease that is yet untreatable? In the research studies, patients are often not told they may have the disease, but in practice in the real world, many may be told.

Are hospitals shortchanging staff on overtime pay?

The federal investigators are looking into the pay practices throughout the healthcare industry after finding that many hospitals and nursing homes do not pay the overtime due to nurses and other staff who work more than 40 hours a week, writes New York Times reporter Robert Pear.

Pear writes:

“Hospitals around the country have paid millions of dollars in back wages to settle claims by the government and their employees. And many more hospitals are fighting class-action lawsuits that raise the same issues.”

“The Fair Labor Standards Act generally requires that employees be paid at least the federal minimum wage of $7.25 an hour, as well as one-and-a-half times their regular rates of pay for hours worked beyond 40 a week.”

WASHINGTON, D.C.—Senators pressed senior military leaders Tuesday to improve their efforts to address traumatic brain injuries, suicide and other wounds suffered by soldiers returning from the wars in Iraq and Afghanistan.

Responding to what he called “disconcerting” reports by NPR and ProPublica, Sen. Carl Levin, D-Mich., said at a hearing before the Senate Armed Services Committee that the military needed to better address the wide range of medical and behavioral problems affecting troops.

Earlier this month, we reported that the military was failing to diagnose and adequately treat troops with brain injuries. Since 2002, official military figures show more than 115,000 soldiers have suffered mild traumatic brain injuries, also called concussions, which leave no visible scars but can cause lasting problems with memory, concentration and other cognitive functions.

But the unpublished studies that we obtained and the experts that we talked to said that military screens were missing tens of thousands of additional cases. We also talked to soldiers at one of the military’s largest bases, who complained of trouble getting treatment.

“I am greatly concerned about the increasing number of troops returning from combat with post-traumatic stress and traumatic brain injuries, and the number of those troops who may have experienced concussive injuries that were never diagnosed,” Levin, chairman of the committee, said as he opened today’s hearing.

Gen. Peter Chiarelli, the Army’s vice chief of staff, said the Army had made strides in identifying soldiers at risk of committing suicide, setting up new treatment centers and deploying a new system of “telemental health services,” allowing soldiers to talk with counselors by computer video chat programs.

Chiarelli’s remarks were echoed by other senior military commanders at the hearing from the Navy, Air Force and Marine Corps.

“Our success notwithstanding, we still have much more to do,” said Chiarelli, who has emerged as the Army’s point man on mental health issues. “We face an Army-wide problem that will be only be solved by the coordinated efforts of our commanders, leaders, soldiers and program managers and health providers. This is a holistic problem with holistic solutions and that is how we’re approaching it.”

Chiarelli acknowledged that the Army continues to have problems with properly diagnosing soldiers with mild traumatic brain injuries, saying that it was an emerging area of medicine. And he acknowledged that soldiers at bases throughout the Army have sometimes had trouble receiving treatment for mild traumatic brain injuries and post-traumatic stress.

Chiarelli took issue with our reporting, however. He said the NPR and ProPublica reports were wrong to blame military doctors for failing to diagnose the problem, or to accuse senior military officials of not taking the issue seriously. He also said that NPR and ProPublica had tried to draw a distinction between traumatic brain injury, or TBI, and post-traumatic stress, or PTS, two conditions which frequently occur together.

“I think the great disservice that NPR did to everyone was to try to isolate TBI from PTS. And that is just not possible,” Chiarelli said. “The co-morbidity of these two is what’s giving us the difficulty today. And I also think that they did a disservice when they indicated that PTS is a psychological problem. It’s not just at a psychological problem. It is a physical injury that occurs.”

Chiarelli did not cite any factual errors in the stories and we stand by our reporting. But we also think he is mischaracterizing our reporting, which was based on dozens of interviews with senior military researchers, commanders and soldiers, and thousands of pages of unpublished studies, e-mails and medical records.

First, we did address the overlap of TBI and PTSD in our stories: “To be sure, brain injuries and PTSD sometimes share common symptoms and co-exist in soldiers, brought on by the same terrifying events,” we wrote.

We also did not downplay the seriousness of PTSD — a wound which NPR has reported on extensively in past stories.

We found several instances in which military doctors expressed skepticism about mild traumatic brain injury and its effects. Dr. Charles Hoge, one of the Army’s senior health advisers, referred to the “illusory demands” of mild traumatic brain injury in an opinion piece in the New England Journal of Medicine last year. In an April 2010 e-mail that we obtained, he wrote: “What’s the harm in missing the diagnosis of mild TBI?” In an interview, Hoge told us that he was concerned with treating soldiers’ symptoms, no matter the cause.

We also turned up extensive evidence that military doctors weren’t diagnosing mild traumatic brain injuries, both on the battlefield and when troops came home. Battlefield medics, overwhelmed by life-threatening wounds, can miss the signs of concussions. Screening tools now in place often fail to catch soldiers who have suffered concussions. Soldiers often try to hide their symptoms to return to battle with their comrades.

One of the Army’s senior neuropsychologists told us of examining five soldiers who had survived a rocket attack in Iraq last year. Medical staff had treated their visible wounds, but failed to diagnose them as suffering from mild traumatic brain injury — even though they were suffering “classic” symptoms, according to Lt. Col. Mike Russell.

It is important to diagnose mild traumatic brain injury and quickly provide treatment for any lingering effects, according to the Pentagon’s own experts. While the majority of soldiers recover quickly from concussions, some report lasting mental and physical problems. Studies show that such soldiers can be helped by providing cognitive rehabilitative therapy, an intensive program to retrain the brain to perform mental tasks.

Sen. Mark Udall, D-Colo., asked Chiarelli several questions about the military’s efforts to improve how it diagnoses traumatic brain injury. Afterwards, he said that he appreciated Chiarelli’s efforts, but planned to continue pressing Army officials on the issue.

Udall “remains concerned about the impact of TBI and PTSD on our service members,” Tara Trujillo, a Udall spokeswoman. “As discussed at the hearing, there is much still to learn, different approaches to take and ways to continue to improve.”

After the hearing, Levin said he was convinced that the services were trying to properly diagnose mild traumatic brain injury.

“I remain concerned about the diagnosis of traumatic brain injuries, and especially of mild traumatic brain injuries, but it is not for lack of the services trying to do the best they can with existing science, tools, and methods,” Levin said in a statement. “There is still much to be learned in both the military and civilian medical environments about the diagnosis, treatment, and care of traumatic brain injury, and its relationship to other combat-related injuries such as post traumatic stress. I believe each of the services is taking the issues of detection, tracking, and follow-up care very seriously, but there is still work to be done.”

WASHINGTON, D.C.–The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan, many of whom receive little or no treatment for lingering health problems, an investigation by ProPublica and NPR has found.

So-called mild traumatic brain injury has been called one of the wars’ signature wounds. Shock waves from roadside bombs can ripple through soldiers’ brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.

Photo: U.S. Army

Officially, military figures say about 115,000 troops have suffered mild traumatic brain injuries since the wars began. But top Army officials acknowledged in interviews that those statistics likely understate the true toll. Tens of thousands of troops with such wounds have gone uncounted, according to unpublished military research obtained by ProPublica and NPR.

“When someone’s missing a limb, you can see that,” said Sgt. William Fraas, a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house. “When someone has a brain injury, you can’t see it, but it’s still serious.”

In 2007, under enormous public pressure, military leaders pledged to fix problems in diagnosing and treating brain injuries. Yet despite the hundreds of millions of dollars pumped into the effort since then, critical parts of this promise remain unfulfilled.

Over four months, we examined government records, previously undisclosed studies, and private correspondence between senior medical officials. We conducted interviews with scores of soldiers, experts and military leaders.

Among our findings:

From the battlefield to the home front, the military’s doctors and screening systems routinely miss brain trauma in soldiers. One of its tests fails to catch as many as 40 percent of concussions, a recent unpublished study concluded. A second exam, on which the Pentagon has spent millions, yields results that top medical officials call about as reliable as a coin flip.

Even when military doctors diagnose head injuries, that information often doesn’t make it into soldiers’ permanent medical files. Handheld medical devices designed to transmit data have failed in the austere terrain of the war zones. Paper records from Iraq and Afghanistan have been lost, burned or abandoned in warehouses, officials say, when no one knew where to ship them.

Without diagnosis and official documentation, soldiers with head wounds have had to battle for appropriate treatment. Some received psychotropic drugs instead of rehabilitative therapy that could help retrain their brains. Others say they have received no treatment at all, or have been branded as malingerers.

In the civilian world, there is growing consensus about the danger of ignoring head trauma: Athletes and car accident victims are routinely tested for brain injuries and are restricted from activities that could result in further blows to the head.

But the military continues to overlook similarly wounded soldiers, a reflection of ambivalence about these wounds at the highest levels, our reporting shows. Some senior Army medical officers remain skeptical that mild traumatic brain injuries are responsible for soldiers’ troubles with memory, concentration and mental focus.

Traumatic brain injuries have been called the “signature wound” of the wars in Iraq and Afghanistan. While improvements in armor and battlefield medicine mean more soldiers are surviving bomb blasts that would have killed them in previous wars, the explosions are leaving some of them with permanent wounds. Mild traumatic brain injuries are difficult to detect as they leave behind no obvious signs of trauma. While many soldiers recover fully from the injury, others are left with persistent mental and physical problems.

The US Veterans Affairs Administration said today it is expanding a pilot program designed to streamline the disability evaluation process over the next several months to 17 additional military installations, including the Naval Medical Center in Bremerton.

The goal of the pilot is to test “a new process that eliminates duplicative, time-consuming and often confusing elements of the two current disability processes of the departments,” the VA says.

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